Provider Demographics
NPI:1336247113
Name:NANDURI, KUSUMA KALYANI (MD)
Entity Type:Individual
Prefix:DR
First Name:KUSUMA KALYANI
Middle Name:
Last Name:NANDURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:12255 FAIR LAKES PKWY
Practice Address - Street 2:KAISER PERMANENTE
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3952
Practice Address - Country:US
Practice Address - Phone:703-934-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD040072207R00000X
MDD0063439207R00000X
VA0101244597207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409407700Medicaid
J0950013OtherBCBS DC
DC0373330700Medicaid
64881302OtherBCBS MD
J0950013OtherBCBS DC
018623C82Medicare ID - Type Unspecified